CITY OF SAN DIEGO PILOT CLEAN SYRINGE EXCHANGE PROGRAM: FINAL EVALUATION REPORT EXECUTIVE SUMMARY MAY 2004 Criminal Justice Research Division Cynthia Burke, Ph.D., Director 401 B Street, Suite 800 San Diego, CA 92101-4231 (619) 699-1900 This research was supported with funding from Alliance Healthcare Foundation and The California Endowment. Findings and conclusions of this study are those of the authors and do not necessarily reflect the official position or policies of Alliance Healthcare Foundation, The California Endowment, SANDAG, or its Board of Directors.
BOARD OF DIRECTORS The 18 cities and county government are SANDAG serving as the forum for regional decision-making. The Association builds consensus, makes strategic plans, obtains and allocates resources, and provides information on a broad range of topics pertinent to the region s quality of life. CHAIR: Hon. Ron Morrison VICE CHAIR: Hon. Mickey Cafagna EXECUTIVE DIRECTOR: Gary L. Gallegos CITY OF CARLSBAD Hon. Ramona Finnila, Mayor Pro Tem (A) Hon. Bud Lewis, Mayor (A) Hon. Matt Hall, Councilmember CITY OF CHULA VISTA Hon. Steve Padilla, Mayor (A) Hon. Patty Davis, Councilmember (A) Hon. Jerry Rindone, Deputy Mayor CITY OF CORONADO Hon. Phil Monroe, Mayor Pro Tem (A) Hon. Frank Tierney, Councilmember CITY OF DEL MAR Hon. Crystal Crawford, Councilmember (A) Hon. Richard Earnest, Mayor (A) Hon. David Druker, Councilmember CITY OF EL CAJON Hon. Mark Lewis, Mayor (A) Hon. Gary Kendrick, Mayor Pro Tem CITY OF ENCINITAS Hon. Christy Guerin, Councilmember (A) Hon. Maggie Houlihan, Mayor CITY OF ESCONDIDO Hon. Lori Holt Pfeiler, Mayor (A) Hon. Ed Gallo, Councilmember (A) Hon. Ron Newman, Councilmember CITY OF IMPERIAL BEACH Hon. Patricia McCoy, Mayor Pro Tem (A) Hon. Diane Rose, Mayor (A) Hon. Mayda Winter, Councilmember CITY OF LA MESA Hon. Barry Jantz, Councilmember (A) Hon. David Allan, Councilmember (A) Hon. Ernie Ewin, Vice Mayor CITY OF LEMON GROVE Hon. Mary Sessom, Mayor (A) Hon. Jill Greer, Mayor Pro Tem (A) Hon. Jerry Jones, Councilmember CITY OF NATIONAL CITY Hon. Ron Morrison, Councilmember (A) Hon. Frank Parra, Deputy Mayor CITY OF OCEANSIDE Hon. Jack Feller, Councilmember (A) Hon. Terry Johnson, Mayor CITY OF POWAY Hon. Mickey Cafagna, Mayor (A) Hon. Don Higginson, Deputy Mayor (A) Hon. Robert Emery, Councilmember CITY OF SAN DIEGO Hon. Dick Murphy, Mayor Hon. Jim Madaffer, Councilmember (A) Hon. Scott Peters, Councilmember CITY OF SAN MARCOS Hon. Corky Smith, Mayor (A) Hon. Pia Harris-Ebert, Councilmember CITY OF SANTEE Hon. Hal Ryan, Councilmember (A) Hon. Randy Voepel, Mayor (A) Hon. Jack Dale, Councilmember CITY OF SOLANA BEACH Hon Joe Kellejian, Mayor (A) Hon. David Powell, Councilmember CITY OF VISTA Hon. Morris Vance, Mayor (A) Hon. Judy Ritter, Councilmember (A) Hon. Bob Campbell, Councilmember COUNTY OF SAN DIEGO Hon. Dianne Jacob, Chairwoman (A) Hon. Greg Cox, Supervisor CALIFORNIA DEPARTMENT OF TRANSPORTATION (Advisory Member) Jeff Morales, Director (A) Pedro Orso-Delgado, District 11 Director METROPOLITAN TRANSIT SYSTEM (Advisory Member) Leon Williams, Chairman (A) Hon. Jerry Rindone, Vice Chairman (A) Hon. Bob Emery, Board Member NORTH SAN DIEGO COUNTY TRANSIT DEVELOPMENT BOARD (Advisory Member) Hon. Judy Ritter, Chair (A) Hon. Tom Golich, Board Member (A) Hon. Ed Gallo, Board Member IMPERIAL COUNTY (Advisory Member) Hon. Victor Carrillo, Supervisor (A) Hon. David Ouzan, Mayor U.S. DEPARTMENT OF DEFENSE (Advisory Member) CAPT Christopher Schanze, USN, CEC Commander, Southwest Division Naval Facilities Engineering Command (A) CAPT Richard Gamble, USN, CEC SAN DIEGO UNIFIED PORT DISTRICT (Advisory Member) Jess Van Deventer, Commissioner (A) Michael Bixler, Commissioner (A) Peter Q. Davis, Commissioner SAN DIEGO COUNTY WATER AUTHORITY (Advisory Member) Hon. Bud Lewis, Director (A) Bernie Rhinerson, Director BAJA CALIFORNIA/MEXICO (Advisory Member) Hon. Luis Cabrera Cuaron Consul General of Mexico As of May 5, 2004 2
CITY OF SAN DIEGO PILOT CLEAN SYRINGE EXCHANGE PROGRAM: FINAL EVALUATION REPORT EXECUTIVE SUMMARY INTRODUCTION AND PROJECT BACKGROUND In 2001, the San Diego City Council authorized the creation of a Pilot Clean Syringe Exchange Program. The purpose of the pilot program was to reduce the sharing of syringes, educate drug users about health issues, and refer these individuals to treatment and other needed services. This final report, which was prepared by independent evaluators from the San Diego Association of Governments (SANDAG), along with recommendations from the Program Facilitation Committee, will be presented to the City Council in August 2004. At that time, the City Council will decide whether and how the program will continue. Injection Drug Use and the Spread of Infectious Disease Injection drug use (IDU) is one of the most common methods of transmission for a number of preventable life-threatening diseases, including the human immunodeficiency virus (HIV) and Hepatitis C (HCV). According to the most recent national statistics, there are currently 886,575 individuals living in the U.S. who are diagnosed with AIDS (Acquired Immunodeficiency Syndrome) 1. Over the years, IDU has been identified as the primary mode of transmission for approximately one-third of these cases. Across the states, California has the second highest number of cumulative AIDS cases among residents and within California, San Diego ranks third among other metropolitan areas. At the end of 2003, there had been a total of 4,273 diagnoses of HIV in the county, 542 of which were associated with IDU. The majority of these diagnosed individuals (over half) reported that they resided in the Central region of San Diego County at the time of their diagnoses 2. With approximately 3.9 million people nationwide infected with HCV, and no vaccine or effective treatment, it is the most common chronic blood-borne infection in the U.S. Like HIV, there is the possibility for a long latency period for HCV, with some HCV-infected individuals not progressing to clinical disease for more than two decades. According to the CDC, almost three-quarters of persons infected with HCV become chronically infected and of these, around one-quarter to one-third will progress to end-stage liver disease requiring liver transplantation 3. The number one cause of HCV transmission, according to recent studies, is IDU 3. Rates of HCV infection are four times higher in young injection drug users than rates of HIV infection and after 1 Centers for Disease Control and Prevention (CDC) (2003). HIV/AIDS Surveillance Report 2002 (14). Atlanta, GA: Author. 2 Health and Human Services Agency (HHSA) (2004). HIV/AIDS Epidemiology Report 2003. San Diego, CA: Author. 3 Centers for Disease Control and Prevention (CDC) (2002). Viral Hepatitis and Injection Drug Users. Atlanta, GA: Author. 3
five years of injecting, as many as 90 percent of IDUs are infected with HCV. There were 2,725 newly diagnosed cases of HCV in San Diego County in 2003, a 163 percent increase from 1998 4. Drug Use and Treatment In 2002, approximately 19.5 million people across the U.S. were current users of some type of illicit drug and from 1999 to 2001, approximately 338,000 people nationwide reported injecting drugs in the prior year. Of these, approximately 14 percent knew or suspected the syringe had been used by someone else before they used it and 16 percent knew or suspected the syringe was used by someone else after they used it 5. Locally, 12 percent of adult arrestees in San Diego County interviewed through the ADAM (Arrestee Drug Abuse Monitoring Program) reported they had injected drugs in the prior year 6. While numerous studies have shown that treatment is effective 7, the demand for treatment, unfortunately, exceeds availability. Findings from the National Survey on Drug Use and Health 5 reveal that approximately 7.7 million individuals who are currently using an illicit drug need treatment. However, only 18 percent actually receive it. Between July 2002 and June 2003, there was a total of 14,367 alcohol and other drug treatment admissions in San Diego County. The average waiting time for admission to a residential program was about seven days 4. Syringe Exchange as a Public Health Intervention Even though the use of federal funds for syringe exchange programs has been restricted by Congress since 1989, research has generally supported the contention that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs 8. Support for syringe exchange programs has also been given by the Department of Health and Human Services (DHHS), the U.S. Conference of Mayors, and the American Medical Association (AMA), among others. Concerns often voiced by opponents, including that syringe programs will attract drugs users to the areas where services are provided, crime will increase, the number of discarded syringes will increase, and the message is given that drug use is acceptable, have not been realized in previous studies documenting program implementation and operation 9,10. 4 Health and Human Services Agency (HHSA) (2004). Personal communication. 5 Substance Abuse and Mental Health Services Administration (SAMHSA) (2003). Results from the 2002 National Survey on Drug Use and Health: National Findings (SMA 03-3836). Rockville, MD: Author. 6 San Diego Association of Governments (SANDAG). Unpublished data. 7 Center for Substance Abuse Treatment (CSAT) (2004). Key Findings of the National Treatment Evaluation Studies (NTIES). [On-line]. Available at www.ncadi.samhsa.gov. 8 U.S. Surgeon General (2000). Evidence-Based Findings on the Efficacy of Syringe Exchange Programs: An Analysis from the Assistant Secretary for Health and Surgeon General of the Scientific Research Completed Since April 1998. Cited in the City of San Diego (2001), Clean Syringe Exchange Program Task Force Final Report. 9 Vlahov, D. & Strathdee, S. A. (2000). Final Report to the National Institute on Drug Abuse: Evaluation of the Baltimore Needle Exchange Program. Grant Number DA09225. 10 Doherty, M.D., Junge, B., Rathouz, P., Garfein, R. S., Riley, E., & Vlahov, D. (2000). The Effect of a Needle Exchange Program on Numbers of Discarded Needles: A Two Year Follow-Up. American Journal of Public Health, 90, 936-939. 4
In October 1999, Assembly Bill (AB) 136 was passed which exempts from criminal prosecution public entities and their agents and employees who distribute hypodermic needles or syringes to participants in clean needle and syringe exchange projects authorized by the public entity pursuant to a declaration of a local emergency due to the existence of a local public health crisis 11. Since that time, 12 Californian jurisdictions, including the City of San Diego, have joined 8 others in declaring a local health emergency. When declaring a local health emergency, the City Council also authorized the City Manager to convene a Task Force to develop the practices and procedures for a one-year clean needle and syringe exchange pilot project. In the Task Force s 2001 final report, the recommendation was made that the City Council continue to declare a state of emergency and implement a privately-funded one-year pilot clean syringe exchange project. This recommendation provided a description of key program elements, including the use of a small motor home to provide services, the issuance of identification cards to program participants, the provision of risk reduction education and case management as part of service delivery, and 1-to-1 syringe exchange with a limit of 50 syringes exchanged per client per visit. Program Implementation Alliance Healthcare Foundation (AHF) and The California Endowment provided funding through their Harm Reduction Funding Initiative. Family Health Centers of San Diego (FHCSD) was selected from a pool of applicants who submitted proposals to provide program services. SANDAG s Criminal Justice Research Division was selected through a competitive process to conduct the evaluation of the program. Site selection for the motor home began in 2002, with staff from FHCSD and the Monger Company (who were subcontracted with to assist in the implementation) working with community groups in Downtown, North Park, and City Heights. These communities were initially recommended by the Task Force based on health data from the County of San Diego Health and Human Services Agency (HHSA) and crime statistics from the San Diego Police Department (SDPD). For the Downtown site, staff met numerous times with the East Village Association and the Downtown San Diego Partnership and also toured the area to identify possible sites. In July 2002, a Downtown site was approved at 15 th Street between F and G Streets. The North Park Planning Committee was identified and contacted for input in selecting the second site. Even though the same process was followed, the selection of this site took longer and was completed in January 2003. This site, at 31 st Street and University Avenue, was approved by the North Park Planning Committee, but was still found to be unacceptable to some North Park property owners and residents. Due to the longer-than-expected time associated with selecting the two sites, as well as funding concerns, a City Heights site was not implemented. Services were first offered at the Downtown site on July 18, 2002 and at the North Park site on February 14, 2003. As part of the community outreach process, program staff made numerous presentations to residents and business owners in the Downtown and North Park areas, door-to-door outreach was done, and tours of the motor home were offered. Program staff also worked closely with representatives from the SDPD. Officers were also available throughout the project period to respond to neighborhood complaints and concerns. Per the direction of the City Council, a Program 11 City of San Diego (2001). Clean Syringe Exchange Program Task Force Final Report. San Diego, CA: Author. 5
Facilitation Committee was appointed by the City Manager to review the program status and other issues of relevance to program implementation. This Committee, which included representatives from the City of San Diego, funder, service provider, evaluator, treatment services, and community members, met on a monthly basis starting in October 2002. Program Services The City of San Diego Pilot Clean Syringe Exchange Program is operated from a motor home at two sites (Downtown and North Park). During each day of operation (Thursday 6:00 p.m. to 9:00 p.m. in Downtown and Friday 10:00 a.m. to 1:00 p.m. in North Park), two staff members provide services to clients inside the motor home and at least one staff member remains outside to greet clients and complete enrollment. Before a client can receive services, s/he is asked to complete the program enrollment process, is informed of program regulations, and receives a laminated identification card. At a client s first visit to the syringe exchange site, s/he can receive an initial harm reduction kit that includes two syringes, educational material, as well as other items that promote safer injection practices. Besides these two syringes, clients can receive no more than 50 syringes at any program visit, regardless of how many they turn in. Standard harm reduction kits (kits without syringes), safer sex kits, and hygiene kits, as well as educational materials and referrals, are available on an on-going basis. As part of the project, street outreach (to facilitate this population accessing services) and case management (a more intensive client-centered intervention aimed at helping clients reduce risks associated with injection drug use and sexual behaviors) are offered in addition to the services provided at the syringe exchange sites. RESEARCH OBJECTIVES AND METHODOLOGY As the outside evaluator of the program, SANDAG utilized the Task Force report to guide the research efforts. The goals of the process evaluation were to document if the program was implemented as planned and describe what types of program services were provided to whom. The primary focus of the outcome evaluation was to measure the effect the program had on clients who received services, as well as the level of criminal activity in the areas surrounding the syringe exchange sites. The results of a telephone survey of North Park community residents (being conducted by researchers from San Diego State University s School of Public Administration and Urban Studies) will be presented in a separate report. At the beginning of the project, researchers from Johns Hopkins University provided oversight and consultation as the research design and instruments were created and finalized. A number of data collection strategies were used to address the research questions. First, program staff documented outreach efforts to the target population. During the course of the project, 6,913 contacts were made, possibly with duplicate individuals (Table 1). In addition, program staff also collected information from the 666 clients who enrolled for program services as part of the intake process and documented the services provided to those individuals who continued to receive services (35 case management clients and 573 through the exchange program). Research staff engaged 132 of these clients in a supplemental research study to collect additional information about their drug use and other risk taking behavior history. Because the evaluation period was relatively short (one 6
year), individuals who had visited the exchange sites at least twice were selected on a first-come basis at each of the exchange sites (76 at Downtown and 56 at North Park). One hundred ten (110) of these individuals were successfully contacted for a follow-up interview approximately three months after their initial research interview. This 83 percent follow-up rate is very high, especially considering the transitory nature of many of these individuals. Because an experimental design could not be used, pre-post comparisons were made from this sample of clients. Statistical significance tests were used to compare Downtown and North Park clients at intake and to also determine if differences between intake and exit for the same group of clients were significant. The significance level used for all tests was p <.05. Table 1 DESCRIPTION OF CLIENT ENROLLMENT AND RESEARCH PARTICIPATION SOURCE: SANDAG 58 Did Not Return to Receive Services 6,913 Outreach Contacts Made 666 Clients Enrolled 35 Received Only Case Management 110 Successfully Contacted for Follow-Up (83%) 573 Received Services at Exchange Site 132 Participated in Supplemental Research 22 Not Contacted 441 Did Not Participate 7
PROGRAM SERVICES This section presents the information documented through the process evaluation, including how many individuals were reached through the outreach process, how many clients exchanged syringes and received referrals at the syringe exchange sites and through supplemental case management, and what types of services these clients received. Answers to research questions from the original Task Force report are presented in Table 2. What Outreach Efforts Did Program Staff Conduct to Reach the Target Population? A total of 6,913 outreach contacts were made by program staff. The purpose of outreach was to provide people with information about FHCSD services, distribute safer injection and safer sex supplies, and inform IDUs about the pilot program. As part of these efforts, over 16,000 harm reduction kits, 4,500 hygiene kits, and 1,800 additional pieces of educational material were distributed. How Many Clients Visited the Syringe Exchange Sites? A total of 666 clients enrolled for program services between July 18, 2002 and February 13, 2004. Of these, 58 did not return to receive program services, 35 received case management only, and 573 enrolled and received syringe exchange services (Table 1). Almost two-thirds (63%) of the clients only visited the Downtown site, 21 percent visited both, and 16 percent only visited North Park. The average number of clients per night was 34.0 at the Downtown site and 16.6 per day at the North Park site. How Many Syringes Did the Program Collect and Distribute? Between July 18, 2002 and February 13, 2004, 146,956 used syringes were turned in and 101,933 clean syringes were distributed. Thus, 45,023 more syringes came in than went out. More syringes were turned in than distributed because some clients only used the program to discard used syringes. What Other Types of Services Did Clients Receive After Enrollment? In addition to exchanging syringes, program clients received almost 8,000 harm reduction kits, almost 2,500 hygiene kits, and over 1,500 additional pieces of educational material. Over 1,100 risk reduction sessions were conducted. 8
What Types of Referrals Did Clients Receive? Five hundred four (504) of the clients received some type of referral, representing almost nine out of every ten clients. These referrals were to Steps to Change (a program specifically working with IDUs), the Wound Care Clinic, detox, health care, hepatitis screening, HIV testing, drug treatment, hepatitis vaccination, food, and shelter, among others. More than two-thirds of these referrals were assisted, which involved a staff person helping the client access the service. Clients were most likely to follow-up on their referral for Steps to Change, food, shelter, and HIV testing. What Factors Kept Clients from Using the Program? The most common reasons that clients gave for not coming to the exchange site were that the times or locations were not convenient. How Satisfied Were Clients with Program Services? Nine out of ten clients reported being very satisfied with program services. 9
Table 2 ANSWERS TO FIVE QUESTIONS POSED IN THE TASK FORCE FINAL REPORT Has Needle Sharing Among Participants Been Reduced? Yes. As a result of the pilot program, clients were significantly less likely to reuse a syringe, to use a syringe someone else had already used, and to give a syringe they had used to someone else. What Has Been the Impact of the Syringe Exchange Program on the Frequency and Type of Drug Use by Participants? Client drug use did not increase as a result of making clean syringes available. In fact, fewer clients reported using cocaine, heroin, and methamphetamine approximately 90 days after enrolling in the program. In addition, their injection frequency did not increase. How Frequently Do Participants Use the Syringe Exchange Program and What Services Do They Utilize, Including Treatment and Medical Care? Between July 2002 and February 2004, 573 clients received services at one of the two syringe exchange sites. Those who initially visited the Downtown site received services an average of three times and those who first visited North Park came an average of two times. Clients turned in almost 147,000 dirty syringes and received around 102,000 clean ones in return. In addition, over half of the clients also received standard harm reduction kits, hygiene kits, educational materials, and risk reduction. Over three-quarters received a referral for some type of service and almost one in five clients interviewed at follow-up reported having participated in detox. What Are the Trends in Criminal Activities Associated With Drug Use in the Surrounding Neighborhood? The number of arrests and crime cases in the one-third mile radius around the Downtown site increased after program implementation. However, there was actually a decrease in police activity on Thursdays when the site was operational, suggesting that other factors may be more closely related to this change. In North Park, while the number of arrests and crime cases did not increase disproportionate to the Western Division, there were more calls for service after February 14, 2003. Where Do Syringe Exchange Program Participants Live? Forty-one percent (41%) of clients who visited the program at least twice reported living in the Downtown ZIP code (92101) and 7 percent reported living in the North Park ZIP code (92104) at the time of program enrollment. The remaining individuals lived in a ZIP code adjacent to one of the two sites (22%), in another City of San Diego community (19%), or in a different city in the County (10%). SOURCE: SANDAG 10
MEASURED PROGRAM OUTCOMES The main focus of the outcome evaluation for this study was on measuring the effect the program had on clients who received services, as well as the level of criminal activity in the areas surrounding the syringe exchange sites. This information was collected from the 110 clients who were contacted for follow-up interviews approximately three months after the initial research interview, as well as official statistics from the SDPD. Did the Frequency of Client Drug Use Increase? Fewer clients were injecting at follow-up. Almost one in five (18%) of the clients reported they had not injected drugs at all in the two weeks before follow-up. Significantly fewer clients reported using heroin and methamphetamine at follow-up (58% and 39%, respectively) than did initially (67% and 54%, respectively). The frequency with which clients injected did not increase. That is, more clients did not inject on a daily basis at follow-up. Did Clients Reuse Syringes Less Frequently? After program enrollment, clients were less likely to reuse a syringe they had already used (42% versus 58%). Clients were less likely to report that they obtained syringes from questionable sources (i.e., off the street) and less likely to throw used syringes away in the trash. However, clients still discarded syringes in other ways besides turning them in to the program, such as giving them to others. Clients were more likely to report injecting in a variety of different places than they did at intake. Did Clients Share Syringes with Others Less Frequently? Clients were less likely to use a syringe someone else had used (25% at intake versus 11% at follow-up) and were also less likely to give a used syringe to someone else (35% at intake versus 22% at follow-up). Were Clients More Likely to Engage in Other Techniques to Reduce Risk? There was no significant change in client behavior related to cleaning their syringes or cleaning their skin before injecting. In addition to syringes, clients were less likely to share cotton and tourniquets, but there was no significant difference in the percentage sharing other drug paraphernalia, such as bottle caps and rinse water. 11
Were Clients Less Likely to Engage in Risky Sexual Behavior? There was no significant change in client sexual behavior within the 90-day follow-up period. Were Clients Better Off in Other Parts of Their Lives? Clients were more likely to have a stable living situation at follow-up and were also more likely to report having some source of income. Did Clients Move to Downtown and North Park? Even though about two in five clients reported moving recently, the percentage of clients living in Downtown or North Park did not increase over time. Did Clients Have More Contact with Law Enforcement? Around two-thirds of program clients had no contact with law enforcement in the three months preceding and following their program enrollment. Those who did have contact were not more likely to be cited or arrested after participation. Did Crime Around the Downtown Site Increase? Police activity around the Downtown exchange site did increase after program implementation, compared to the one year prior. Specifically, a greater number of arrests and crime cases were logged. However, crime did not increase disproportionately on Thursdays, when the site was operational, and in fact decreased, suggesting that other factors were more predictive of the change, such as redevelopment in different parts of the Downtown area. Did Crime Around the North Park Site Increase? While the number of crime cases and arrests documented by the SDPD did not increase a disproportionate amount after February 14, 2003 (when the North Park site began operating), the number of calls for service and citations in the one-third mile radius around the site did increase. The increase in calls for service is indicative of increased community concern from residents in this area. 12
CLIENT INFORMATION Information regarding the 666 clients who enrolled to receive program services at one or both of the exchange sites was captured by program staff at the intake interview. Additional information was also available for a sample of 132 clients who agreed to participate in the research component. What Were the Demographic Characteristics of Clients? Most of the clients were male and the average age was about 40. North Park clients were more likely to have completed high school, be employed, have some source of income, and live in a stable residence, compared to the Downtown clients. As previously noted, 58 clients did not return to receive services after enrolling. These individuals were more likely to have been Hispanic, older, and to inject heroin (rather than methamphetamine), compared to those who did return for services. Where Did Clients Live at Program Intake? Three-quarters of Downtown clients and two-thirds of North Park clients lived in one of these two areas or one of the other communities immediately adjacent to them. Around one in ten of the clients lived in a city other than San Diego. Downtown clients were more likely to report that they walked to the site and that they lived in closer proximity to it. What Was the Drug Use History of Clients? Clients had a lengthy substance use history, with around two-thirds or more having used alcohol, marijuana, crack, cocaine, heroin, and methamphetamine in their lifetime. Downtown clients were significantly more likely to have used heroin. Over half of the clients had experienced a drug overdose at one point in their life. What Was the Recent Injection History of Clients? Over half of Downtown clients reported injecting heroin on a daily basis. One-third of North Park clients reported injecting methamphetamine this frequently. How Did Clients Get, Use, and Discard Syringes Before the Program? Before the program, clients were most likely to report they got syringes off the street or from a friend and they were most likely to report they injected in their home. 13
Before they used the pilot program, most clients threw used syringes away in the garbage or dumpster. Why Did Clients Come to the Program? Clients were most likely to hear about the program by word-of-mouth and were most likely to come because they wanted clean syringes. The majority of clients said they were getting syringes just for themselves. How Were Program Clients at Risk? Over two-thirds of Downtown clients and almost half of North Park clients reported that they reused syringes. About three-quarters of clients said they did not always break the needle off the syringe when they were done and about one-quarter reported having been accidentally stuck by a dirty needle accidentally. More than one in four clients reported giving used syringes to others, as well as using a syringe that someone else had already used. Almost half of Downtown clients and around one-third of North Park clients always injected with other drug sharing partners. Less than one-quarter of clients reported cleaning their syringes properly (with both water and bleach) and an equally small percentage reported proper skin-cleaning practices. Many clients practiced unsafe sex, including having sex without a condom when they were high, with someone who injects drugs, or with someone who was HIV positive. Over half of the clients reported sharing drug paraphernalia, including bottle caps, cotton, rinse water, and tourniquets. Half of program clients lacked medical insurance. What Services Had Clients Previously Received? Over half of the clients had previously been in detox or treatment. About one in ten had been turned away from detox or treatment services in the previous 60 days. 14
SUMMARY AND CONCLUSIONS The evaluation of the City of San Diego Pilot Clean Syringe Exchange Program supports previous research which has shown that providing clean syringes to injection drug users is associated with decreased reuse and sharing of dirty syringes. In addition, San Diego program clients did not increase the frequency of their drug use or injection behavior and were less likely to share some types of drug paraphernalia. There were no significant improvements, however, in other high-risk behaviors, including syringe-cleaning and unsafe sex. While police activity around the Downtown exchange site increased over the period of program operation, it did not increase disproportionately on Thursdays when the site was operational. Police responded to a greater number of calls for service around the North Park site after program implementation, but did not make a significantly greater number of arrests. As a result of the program, almost 147,000 used syringes were turned in and around 102,000 clean ones were distributed. In addition, clients who utilized the exchange services and case management received a variety of referrals and other services. These included detox and drug treatment, basic necessities such as food and shelter, as well as Hepatitis screening and vaccination. Most of these clients lived in the Downtown area or in another neighborhood near one of the exchange sites. A significant number of individuals also received harm reduction kits, educational materials, and referrals for service through outreach efforts. EVALUATOR RECOMMENDATIONS The following recommendations, based on the results of this research, are offered by the evaluation team: Continue to declare a state of emergency. Recent county-wide health statistics are still alarmingly high and according to local experts, may undercount the actual number of HIVand HCV-positive individuals in the region. While program participants made positive lifestyle changes in some areas of their lives, many potential clients may not have felt comfortable using the program at this point in time and those who have used the program might fall back into using unsafe injection practices if the program was no longer available. Work with the County of San Diego to address this public health problem on a regional basis. Other California counties who have declared a state of emergency have done so at the county-wide level. While most of the pilot program participants lived in the City of San Diego, the participation and support of the County s Health and Human Services Department would be a useful addition in addressing this regional problem. Conduct more community outreach to educate citizens about the program and continue to offer them the opportunity to provide feedback. Residents are impacted both positively and negatively by what goes on in their communities. It is important that community members are provided accurate information about the program and also that the city continues to give them channels to express their opinions. 15
Consider changing the time and location that services are offered if necessary. Some program clients were dissatisfied with the limited places and times the motor home was available to offer exchange services. In addition, a number of North Park residents remained dissatisfied with the location of the second exchange site. If the program continues, it may be appropriate to examine additional options that would better meet the needs of the clients, as well as address the concerns of residents. Remove the limit of 50 syringes per exchange to ensure that individuals who inject more frequently do not reuse or share dirty syringes. The results of this impact evaluation show that clients did not inject more frequently when they had clean syringes available. However, they did continue to provide used syringes to others. Removing this limit or increasing it would be another step toward reducing clients risk of being infected or transmitting HIV or HCV. Continue to focus on addressing other risky behaviors of clients. While clients were less likely to reuse or share syringes, or to share some drug paraphernalia, there were no significant changes in other risk behavior in the first three months of program participation. Program staff should continue to work with clients as they develop relationships with them so that positive change can also be made in other areas, such as skin-cleaning, syringe cleaning, and sexual behavior. 16